ESSENTIAL CERTIFICATE

Name of the Claimant - Jaspal Singh Period of Treatment

Designation ASI No. 41/PKL indoor/outdoor- Indoor
Basic Pay/pension 34900/-
Police Department, Haryana

I certify that Mrs. Shree Kaur mother of Sh. Jaspal Singh employed in the office of the
Commissioner of Police, Panchkula has been under my treatment in the Shri Balaji Aarogyam Hospital (name of
the hospital/dispensary consulting room and that the under mentioned medicines prescribed by me in this
connection were absolutely essential in the __________________ (name of the hospital/dispensary) for the
supply to the patient and do not include preparation for which cheaper substitute of equal therapeutic value are
available not preparation are primary food/toilets of disinfection.
CERTIFIED THAT
1. The medicines have not cheaper effective substitutes.
2. The treatment given was indoor/outdoor.
3. The price claimed is reasonable.
4. The medicines are not in the nature of tonics of food or vitamins etc. the cost which is not re-imburseable
in the Govt. orders issued on this subject from time to time.
5. He/she was suffering from _____________________________________ (in capital letters)
Sr. Name & Quantity of medicines Outdoor/indoor ticket No. & date Date on which Rs. Ps
No. on which actually prescribed actually purchased

1.

2.

3.

4.

5.

6.

7.

8.

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14.

15.

IN CASE INDOOR TREATMENT SIGNATURE & STAMP OF

Certified that the medicines claimed the AMA (in Capital Letters)
In this bill are as per head ticket
No. ______________________
CERTIFIED THAT
1. The medicines have actually been purchased by me during the course of treatment.
2. I am living in Village-Untsal, Post Office-Kaulapur, District -Kurukshetra.
3. In case of wife/children that the patient Mr./Mrs./Miss _________________________________ is my
_____________________ and he/she is wholly dependent upon me and is residing with me and unmarried
and unemployed in case of sons/daughters.
4. For parent only :
His/her totally income does not exceed Rs. 3500/- P.M. My mother is/are residing with me at Village-Untsal,
Post Office-Kaulapur, District -Kurukshetra..
5. In case spouse of working :-
a) Certified that my wife/husband is not getting any fixed medical allowance from any medical source.
b) Certified that my wife/husband is employed and is not getting any medical re-imbursement, and affidavit
to this effect has already been furnished.
c) Certified that I am not an adhoc employee and am working on regular basis.
d) Certified that I am not getting fixed medical allowance due to chronic disease patient (in case of chronic
disease patient).

Place :- Panchkula Signature of the Claimant

Date :- Name:- JASPAL SINGH
(in Capital Letters)
Designation :- ASI No. 41/PKL